WoodGreen’s clinical social workers strive to fill gaps in care for clients living with complex health and psychosocial issues. Our Comprehensive Care and Integration Specialists connect clients to essential services and supports; coordinate follow-up care; and provide case management, counselling and advocacy on housing, legal, financial and immigration issues.
We work with clients to develop individual Coordinated Care Plans and support their care providers to work as a team. Our goal is to bridge the gap between acute and medical care providers and the community sector.
- Patients/clients with significant gaps in care
- Patients/clients who may struggle to follow up on care recommendations
- Patients/clients who have a history of multiple Emergency Department (ED) visits, are Alternate Level of Care (ALC) or at risk for ongoing visits and in-patient stays
- Patients/clients who experience challenges related to the social determinants of health (e.g., housing, income)
- Patients/clients who would benefit from integrating the work of multiple health providers
Please consider referring clients with complex health needs from the following groups:
- Individuals experiencing mental health and/or addiction issues
- Psychogeriatric populations (55+ with mental health and/or addiction issues)
- Frail elderly